Lost lives and opportunities for the legacy of harm reduction in Scotland, UK
Authors: Catherine Maria Comiskey
Journal: The Lancet Public Health (2023)

Globally, the legacy of the Harm Reduction Philosophy among people who use opiates is impressive.1Harm Reduction InternationalWhat is harm reduction?.https://www.hri.global/what-is-harm-reductionDate: 2019Date accessed: April 28, 2023Google Scholar The International Harm Reduction Association defines harm reduction as policies, programmes, and practices that aim primarily to reduce the adverse health, social, and economic consequences of the use of legal and illegal psychoactive drugs without necessarily reducing drug consumption; harm reduction is intended to benefit people who use drugs, their families, and the community.1Harm Reduction InternationalWhat is harm reduction?.https://www.hri.global/what-is-harm-reductionDate: 2019Date accessed: April 28, 2023Google Scholar This philosophy is embedded in the public health and human rights approach of the 1948 UN Universal Declaration of Human Rights, which states that all human beings are equal in dignity and rights.2UNUniversal Declaration of Human Rights.https://www.un.org/en/about-us/universal-declaration-of-human-rightsDate: 2019Date accessed: April 28, 2023Google Scholar Unfortunately, the work by Andrew McAuley and colleages3McAuley A Fraser R Glancy M et al.Mortality among individuals prescribed opioid-agonist therapy in Scotland, UK, 2011–2020: a national retrospective cohort study.Lancet Public Health. 2023; (published online June 6.)https://doi.org/10.1016/S2468-2667(23)00082-8Google Scholar in The Lancet Public Health clearly shows that those who use opiates in Scotland, UK, are less equal in their human rights and their access to adequate health care. We know from previous systematic reviews that the harm reduction approach of prescribing opiate agonistic treatment (OAT) to those who use opiates reduces the risk of mortality and saves lives.4Santo Jr, T Clark B Hickman M et al.Association of opioid agonist treatment with all-cause mortality and specific causes of death among people with opioid dependence: a systematic review and meta-analysis.JAMA Psychiatry. 2021; 78: 979-993Crossref PubMed Scopus (126) Google Scholar McAuley and colleagues’ research3McAuley A Fraser R Glancy M et al.Mortality among individuals prescribed opioid-agonist therapy in Scotland, UK, 2011–2020: a national retrospective cohort study.Lancet Public Health. 2023; (published online June 6.)https://doi.org/10.1016/S2468-2667(23)00082-8Google Scholar delves deeper and explores factors associated with mortality in Scotland. Using a retrospective cohort approach, the authors analysed a prescription-based database of individuals with opioid use disorder who received at least one OAT prescription between Jan 1, 2011, and Dec 31, 2020. A cohort of 46 453 individuals was obtained. At recruitment in 2011, two thirds were male, over half were older than 35 years, and over half were residents in the most deprived quintile in Scotland. Almost 7000 participants died during the 10-year period of the study and just over 4000 were drug-related deaths. A range of appropriate Poisson regression models adjusted for confounding were implemented to analyse these deaths. The greatest predictors of all-cause mortality were being off OAT at time of death, older age, having a diagnosis of non-chronic hepatitis C virus (HCV), and having a previous non-fatal overdose admission. The authors in their specific analysis of purely drug-related mortality found that despite adjusting for age and other cofounders, the risk of a drug-related death increased over time for both people off and on OAT.3McAuley A Fraser R Glancy M et al.Mortality among individuals prescribed opioid-agonist therapy in Scotland, UK, 2011–2020: a national retrospective cohort study.Lancet Public Health. 2023; (published online June 6.)https://doi.org/10.1016/S2468-2667(23)00082-8Google Scholar Although the authors highlight the limitations of their research, there is clearly a significant challenge with the implementation of the true harm reduction philosophy in the Scottish context.3McAuley A Fraser R Glancy M et al.Mortality among individuals prescribed opioid-agonist therapy in Scotland, UK, 2011–2020: a national retrospective cohort study.Lancet Public Health. 2023; (published online June 6.)https://doi.org/10.1016/S2468-2667(23)00082-8Google Scholar Dole and Nyswander5Dole VP Nyswander M A medical treatment for diacetylmorphine (heroin) addiction: a clinical trial with methadone hydrochloride.JAMA. 1965; 193: 646-650Crossref PubMed Google Scholar in their seminal work almost 60 years ago proposed a new approach to the treatment of heroin addiction, one that substituted the use of heroin with methadone supported by a comprehensive range of additional supports. It was from this work that the Harm Reduction Philosophy, which encompasses a non-judgemental approach supplemented with a wide range of health and social services, was formed. Reviewing the findings of this Scottish study3McAuley A Fraser R Glancy M et al.Mortality among individuals prescribed opioid-agonist therapy in Scotland, UK, 2011–2020: a national retrospective cohort study.Lancet Public Health. 2023; (published online June 6.)https://doi.org/10.1016/S2468-2667(23)00082-8Google Scholar from a health service delivery perspective, several important opportunities for possible intervention might have been missed. Predictors of mortality included having a previous non-fatal overdose admission and a confirmed diagnosis of non-chronic HCV. Both predictors would have included specific encounters with health-care professional teams and potential opportunities to link people into relevant harm reduction services. The study findings show that drug-related death risk increased over time after adjustment for age and other confounders for both people off and on OAT. The Public Bodies Act of 2014 changed the way health and social cares services were to be delivered across Scotland.6The Scottish ParliamentPublic Bodies (Joint Working) (Scotland) Act.https://www.legislation.gov.uk/asp/2014/9/contents/enactedDate: 2014Date accessed: April 28, 2023Google Scholar The Act required local authorities and health boards to work together to plan and deliver adult community health and social care services. This way of working was referred to as integrated care and was intended to enhance the delivery of services and improve outcomes for the people of Scotland. Given the findings from this research, the question needs to be asked whether those related services who encounter people who use opiates have potentially missed opportunities to integrate and retain their clients within services and if so, why? Going forward, it needs to be asked, not only in Scotland but elsewhere, if the Harm Reduction Philosophy is failing. Or is it simply the case of us failing to deliver a truly informed and integrated harm reduction service that provides the essential health and social care, and meets the basic human rights of people who use substances. I declare no competing interests. Mortality among individuals prescribed opioid-agonist therapy in Scotland, UK, 2011–20: a national retrospective cohort studyDrug-related mortality rates among people with opioid use disorders in Scotland increased between 2011 and 2020. OAT remains protective but is insufficient on its own to slow the increase in DRD risk for people who are opioid dependent in Scotland. Full-Text PDF Open Access